A 13 year old boy presents to ED having fallen off his scooter complaining of a painful limp.

He was seen by his GP 2 weeks prior to this with similar pain and was diagnosed with a groin strain.

1. What would you look for on clinical examination?
  • Look – is he weight-bearing? Any scars, swelling, skin changes? (specifically does he have a limp, or is he out-toeing?)
  • Feel – Any palpable tenderness, warmth?
  • Move – Passive and active. Does he have reduced painful internal rotation and reduced abduction?
2. What might you consider in the differential diagnosis?
  • Groin strain
  • Slipped Upper Femoral Epiphysis (SUFE)
  • Osteitis pubis
  • Osteomyelitis
  • Septic arthritis
  • Stress fracture/pelvic fracture
  • Avascular necrosis
3. What does the X-ray show?
  • The X-ray, although subtle shows a left sided slipped upper femoral epiphysis = SUFE.
  • The classic X-ray sign of this is that the femoral head looks like a ‘melting ice-cream’. (This is more obvious in this case on the post-operative films). More subtle SUFEs need to be assessed using Kline lines. (see the further reading section).
4. What are the risk factors for this condition?
  • Boys are three times more likely to get this condition than girls.
  • The peak onset is early teenage years (age 13) (although girls tend to get it a little younger due to earlier puberty – age 11).
  • It is commoner in the left hip than the right
  • It is bilateral in 20-40%
  • There is the possibility of a genetic susceptibility.
  • Obesity
  • Endocrine disorders
5. How should the patient be managed?
  • Analgesia
  • Follow the limping child pathway
  • If suspected – bed-rest and refer to orthopaedics for surgical fixation
6. What are the complications of this condition?
  • Avascular necrosis of the femoral head
  • Chondrolysis (degeneration of the articular cartilage)
7. What is the Southwick Angle?
  • This is a radiographic angle used to measure the severity of a SUFE.